Pakistan is the country with the highest population in the region. It is neighboring Afghanistan and is in the transit root of trafficking Opioids to other countries. Several studies have been conducted on drug use. Four rounds of integrated bio-behavioral surveillance on injecting drug use have been carried out. The studies have provided valuable information for policy making and service planning (Pakistan Ministry of Narcotics Control, 2007; Pakistan National AIDS Control Program, 2005, 2006-7, 2008, 2012). In the year 2006, the country estimated the number of Opioid users to be 628,000 from which 77% were Heroin users (Pakistan Ministry of Narcotics Control, 2007; UNODC, 2011). Estimations for the number of PWIDs vary between 84,000 (Khan, A. A., et al., 2011) to 125,000 (Pakistan Ministry of Narcotics Control, 2007). Karachi, Faisalabad and Lahore have the highest proportion of PWIDs (Pakistan MoH, 2012). Common drugs of injection are Avil (injection containing the antihistamine Pheniramine) in most cities, and Heroin in other cities followed by Temgesic and Benzodiazepines (Pakistan National AIDS Control Program, 2012). PWIDs are highly concentrated in large cities, and typically are men, with a very low level of education and are homeless (Pakistan National AIDS Control Program, 2012). Treatment for drug abuse is available through private clinics and NGOs. The program consists of detoxification and rehabilitation. In 2006, 17% of Opioid users were treated for Opioid use in the last year. The majority of DUs had considered access to treatment as difficult (Pakistan Ministry of Narcotics Control, 2007).

Pakistan has a low HIV prevalence in the general population (Pakistan MoH, 2012). Repeated IBBS done on several MARPs have showed that HIV is most prevalent in PWIDs, followed by Hijra (transgender) sex workers (HSWs). The 2011 IBBS conducted on around 5000 PWIDs in 16 cities showed a 37.8% weighted HIV prevalence, which was highest in Faisalabad and Karachi (Pakistan National AIDS Control Program, 2012). Most of the previous studies also showed a range of 11% to 51% (Achakzai, et al., 2007; Altaf, et al., 2009; Bokhari, et al., 2007; Pakistan National AIDS Control Program, 2005, 2006-7, 2008; Platt, et al., 2009). Unsafe injection practices are high and HIV knowledge is moderate among PWIDs. There is a large variation between cities on risk behaviors (Pakistan National AIDS Control Program, 2008, 2012). In 2008, a study in Punjab showed a 15% HIV prevalence among spouses and female partners of men who inject drugs (Pakistan MoH, 2012).

Pakistan is developing its third program (2012-2016). It explicitly addresses PWIDs as the main at risk group and acknowledges harm reduction strategies. However, OST is not planned. Pakistan is the first country of the region that started needle and syringe distribution. In 2011, almost 4 million syringes have been distributed to close to 20,000 PWIDs (Pakistan MoH, 2012). The 2011 IBBS showed that 45% of PWIDs had received free syringes in the previous month (Pakistan National AIDS Control Program, 2012). Another study provided evidence for good coverage, effectiveness and impact of Pakistan's NSP, but it showed that the overall cost is high compared to regional and international experiences (Khan, A. A., et al., 2011). The number of centers providing VCT and their uptake is low. There are 17 centers providing ART and the country has planned to increase those receiving ART (Pakistan MoH, 2012). Since the beginning of the HIV response; NGOs and CSOs have been actively engaged in providing services. There are over 50 AIDS organizations. NGOs are also involved in decision-making and are recipients of a GFATM grant (Pakistan MoH, 2012).

The country reports a decrease in coverage of HIV prevention services for PWIDs in the last two years (Pakistan MoH, 2012). As the country is in need of a nationwide scale-up of HIV prevention, treatment and care over the long-term, mobilizing internal and external resources have been major challenges for the health sector. The country is currently receiving a GFATM Round 9 grant, which was designed to assist Pakistan’s transition towards a more comprehensive coverage of HIV services. HIV prevention for PWIDs, as well as engagement of HIV positive PWIDs in treatment is envisaged as a priority for the country. There is a need to manage expenditures in more cost-effective means. VCT needs to be expanded, improved and utilized effectively. There is also a major benefit in improving drug abuse treatment services and provision of OST. Such a treatment demand exists currently, as it is being provided unofficially and without a standard protocol in private practice (Khan, 2012; Khan, A. A., et al., 2011).